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Review Article | DOI: https://doi.org/10.31579/2692-9406/019
*Corresponding Author: Anthony Kodzo-Grey Venyo FRCS (Ed), FRCSI. North Manchester General Hospital, Department of Urology, Manchester M8, MRB. United Kingdom.
Citation: I Klaus, A N Khan, K-G V Anthony. (2020) COVID-19 Pneumonia: A Review of Typical Ct Findings and Differential Diagnosis. Biomedical Research and Clinical Reviews. 1(3); DOI: 10.31579/2692-9406/019
Copyright: ©2020 Anthony Kodzo-Grey Venyo, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 24 August 2020 | Accepted: 05 October 2020 | Published: 08 October 2020
Keywords: pneumonia; differential diagnosis; imaging; covid-19 pneumonia
Pneumonia that is caused by the 2019 novel coronavirus (SARS-CoV-2, which is also referred to as 2019-nCoV recently did break out in Wuhan China has been coined the terminology of COVID-19. With the spread of the disease, similar cases of COVID-19 had been confirmed in various regions of the world. Because COVID-19 is a relatively new global disease, clinicians, and patients across the globe would initially not be conversant with the clinical features and radiology imaging characteristics of SARS-CoV-2 pneumonia. The causes of pneumonia are protein, many secondary to an underlying cardiorespiratory abnormality while some are related systemic disease. Various imaging techniques generally diagnose cases of Pneumonia. In the current climate, COVID-19 Pneumonia has taken center stage; confirmation relies upon microbiological studies such as real-time polymerase chain reaction or sequencing. These investigations are not usually available in an emergency setting. Computed Tomography (CT) can be used as an essential complement for the diagnosis of COVID-19 Pneumonia in the current epidemic context. But the later may be misleading as other cases of Pneumonia, and interstitial lung disease can easily be confused with COVID-19 Pneumonia. Also, Covid19 Pneumonia may be missed if not considered. The attention of clinicians should be alerted to the possibility of COVID-19 to conduct the appropriate tests to confirm or negate the diagnosis of COVID-19. In asymptomatic as well as in symptomatic patients that have COVID1-9 pneumonia, the initial COVID-19 nuclei acid test results could be normal, which upon subsequent repeat testing would become normal. Still, radiology imaging using a CT scan of thorax would tend to demonstrate various non-specific features that affect a variable number of lobes of the lungs, and these features quickly increase in size when a repeat CT scan of the thorax is undertaken. These findings tend to predate positive COVID-19 test results in some cases of COVID-19. The non-specific changes tend to resolve when the patient resolves from COVID-19 pneumonia. A catalog of radiology images that demonstrate various types of cardio-pulmonary lesions which when encountered by clinicians should alert them to exclude the possibility of COVID-19 Pneumonia has been included in the paper as an aid to alerting clinicians to have a high index of suspicion of radiology images of the thorax which should help them to quickly undertake appropriate tests to confirm or negate the diagnosis of COVID-19 pulmonary infection.
Pneumonia is a common illness and no respecter for age or gender. Imaging is generally the prime investigation. In the present, climate consideration of Covid19 is essential, and early diagnosis can be lifesaving. Corona Virus pandemic is an extremely new medical condition that has pandemically affected the entire world suddenly with recordings of varying incidence rates and deaths in all the continents and countries in the world; it would be envisaged that both clinicians of all specialties including radiologists and patients would tend not to be familiar with the clinical manifestations, laboratory investigation diagnostic features of the disease. It is also likely that some radiologists globally would not have encountered cases of Covid19 pneumonia/pneumonitis before; therefore, it would be possible that these radiologists would tend not to be familiar with the radiology imaging features of the disease.
It has been emphasized that the standard of reference for confirming COVID-19 relies on microbiological tests such as real-time polymerase chain reaction (RT-PCR) or sequencing. However, these tests might not be available in an emergency setting. Computed tomography (CT) can be used as an essential complement for the diagnosis of COVID-19 pneumonia in the current epidemic context. In this review, we present the typical CT features of COVID-19 pneumonia and discuss the main differential diagnosis. [1] The cases of COVID19 Pneumonia reported worldwide have been pitched at 20.9M, of which 13M have recovered, and 760K lost their life. [2]
To review the selected data of COVID19 Pneumonia with a particular emphasis on imaging and differential diagnosis of COVID19 Pneumonia and its mimics.
PUBMED, Yahoo, Google, Google Scholar, and other search engines were searched were used, and references were utilized to write the review of the literature. Additionally, we used our data from Klaus et al. to provide various cardiopulmonary radiology images when encountered by clinicians to alert them to undertake appropriate tests to confirm or negate the diagnosis of Covid19 and to ensure a correct diagnosis is quickly established.
Results / Literature Review
(A) Miscellaneous narrations and discussions from some case report case series, and studies related to Covid19 pneumonitis/pneumonia.
Mimics and chameleons of COVID-19 Pneumonia: [3].
Nickel and Bingisser [3] emphasized that mimics are pathological/physiological entities that closely simulate a remote object, an example being unilateral weakness due to hypoglycemia that mimics a stroke. Nickel and Bingisser [3] also stated that, on the other hand, chameleons often tend to be overlooked or confused with or mistaken for existing underlying pathologies. Nickel and Bingisser [3] additionally stated that within the present-day context, it is essential/vital that "mimics and chameleons" are understood so as not to confuse them with COVID-19 Pneumonia.
Nickel and Bingisser [3]reported an 83-year-old patient who was transferred to the emergency department according to having sustained a fall. As he had sustained thoracic trauma, a CT scan of his chest was performed, which revealed bilateral, sub-pleural, ground-glass opacities with air bronchograms. The patient was afebrile and did not have a cough. Fortunately, he was immediately diagnosed with COVID-19 and admitted. Nickel and Bingisser [3] emphasized that the first case of Covid-19, in Basel, Switzerland, was first reported on the 25th of February 2020, which was just a few days pursuant to the first report of Covid-19 in Italy. Based upon the fact that Covid-19 had previously not been encountered, their experience with Covid-19 was short and that lessons need to be learned quickly from experience gathered concerning the treatment of such cases. Nickel and Bingsser [3] pointed out that a recent study had illustrated that abnormal lung computed tomography (CT) scan findings could be present in "asymptomatic" patients who are suffering from COVID-19 pneumonia [4] Nickel and Bingisser [3] pointed out that such results were recorded by Xie et al. [5] even before viral RNA became detectable Nickel and Bingisser [3] explained that the recent recognition could explain the finding of CT scan findings of abnormalities within the lung preceding the viral RNA detection that current tests do lack sensitivity. Hence, infections could, therefore, be missed [6] Nickel and Bingisser [3] made the ensuing summations related to COVID-19 infections:
Nickel and Bingisser [3] reported another patient who was an 80-year-old woman who had been living in a residential care home who had manifested in the emergency department with dyspnoea as well as cough. The referring family physician suspected that the patient might have COVID-19 because two other residents within her care home had already been diagnosed as having COVID-19 infection. According to extensive assessment workup, she was diagnosed as having decompensated heart failure as the most likely cause of her diffuse lung infiltrates because she had nasal as well as pharyngeal swabs, and their study demonstrated negative results for SARS CoV2. Nickel and Bingisser [3] believed that the second case could be named or referred to as “COVID-19 mimic” in analogy to “stroke mimics,” which are presentations of non-vascular disease manifesting with a stroke-like clinical picture as coined by Huff. [8] Other summations made by Nickel and Bingisser [3] included:
Based upon lessons learned from the summations of Nickel and Bingisser [3] it would be argued that there an urgent need to investigate asymptomatic individuals who are asymptomatic and have undergone radiology imaging that has shown abnormalities within the lungs as well as individuals who have cardiopulmonary symptoms who have been revealed based upon radiology imaging to have various abnormalities within their lungs, pleura, and pericardium to ascertain quickly if they have COVID-19 Pneumonia so that they can be supported medically as well as isolated early to avoid other individuals getting COVID-19 infection. The lesson learned from the summations also illustrates that clinicians need to be aware that several patients who are shown to have cardiopulmonary lesions may not have COVID-19 infection at all and early testing to exclude COVID-19 in this COVID-19 pandemic era would re-assure individuals who do not have COVID-19 but rather cardio-pulmonary disease.
Li et al. [11] stated that the outbreak of corona virus disease (COVID-19) has made the medical management of colorectal cancers difficult. Li et al. [11] made summating iterations related to cancer patients and coronavirus as follows:
These decisions by urologists and other surgeons do always rely upon radiology imaging findings of radiologists who always discuss their results collaboratively with the multi-disciplinary team.
Chen et al. [12] analyzed the clinical characteristics of 2019 novel coronavirus (2019-nCoV) pneumonia as well as to ascertain the correlation between the results of serum inflammatory cytokines and the severity of the disease. Chen et al. [12] emphasized that 29 patients who had 2019-ncov had been admitted to the isolation ward of Tongji Hospital that was affiliated to Tongji Medical College of Huazhong University of Science and Technology in January 2020 who had been selected as subjects of the study. Chen et al. [12] collected the clinical data, and they analyzed the general information, clinical symptoms, the results of the blood tests, as well as the computed tomography (CT) scan imaging features of the patients. Based upon relevant diagnostic criteria, the patients were subdivided into three groups as follows: (a) mild disease group that included 15 patients, (b) severe disease group that consisted of 9 patients, and (c) critical disease group that comprised of 5 patients. They did analyze the expression levels of inflammatory cytokines, as well as other markers within the serum of each group of patients, were detected, and the changes of these indicators of the three sub-groups were compared, including their relationship with the clinical sub-classification of the disease. Chen et al. [12] summated the results as follows:
Based upon lessons learned from the case publication of Chen et al. [12] it would be argued that utilization of high-resolution CT scan of the thorax in asymptomatic individuals and individuals who manifest with respiratory tract symptoms who are affected by 2019-nCoV pneumonia would tend to demonstrate various lesions within the lung that are not specific to 2019-nCoV pneumonia including ground-glass opacities associated with other lesions but which should alert the clinician to be mindful of instituting tests that would confirm or negate the diagnosis of 2019-nCoV pneumonia. Within the developed countries, computed tomography (CT) scanners and magnetic resonance imaging (MRI) scanners tend to be readily available. Hence, various small cardiopulmonary lesions could be easily identified by radiologists and clinicians. Nevertheless, within some parts of developing countries, CT scans and MRI scans are not available. If they are available, they tend to break down, and the repair work on as well as restoration of the scanners to full functioning states tend to be delayed. For this reasons, it would be envisaged that perhaps some radiologists and clinicians may not be conversant with the features of ground-glass opacities and other subtle, as well as overt lesions which though not diagnostic of 2019-nCoV pneumonia, should alert all clinicians to undertake investigations that would confirm or negate the diagnosis of 2019-nCoV pneumonia to ensure those who have 2019-nCoV pneumonia are isolated and treated. Those who do not have 2019-nCoV pneumonia are re-assured. Within the latter part of this article, we have included various radiology imaging features which though not specific to 2019-nCoV pneumonia should alert clinicians to the fact that they should exclude the possibility of 2019-nCoV pneumonia whether the individuals are asymptomatic, or they have respiratory tract symptoms whether or not they also have a malignant disease or any other disease elsewhere.
An et al. [13] had stated that from December 2019 to the time of the report of their cases, the outbreak of the novel coronavirus had impacted nearly more than 90,000 individuals in more than 75 countries. An et al. [13] had aimed to define within their case report the chest computed tomography (CT) scan findings of 2019-novel coronavirus that was associated with pneumonia as well as its successful resolution under treatment. An et al. [13] reported a fifty-year-old woman who is a businesswoman who had manifested with the main symptom of fever over the preceding one week, diarrhea, anorexia, as well as asthenia”. In the first instance, she was given Tamiflu treatment. She had influenza A virus serology, and the result was negative. She was commenced on levofloxacin 3 days subsequently because her symptoms had not improved. She had the novel coronavirus nucleic acid test, which was negative. It was noted that before the onset of her disease, she had been to Wuhan on a business trip. Despite having taken her levofloxacin medicament, her symptoms had not improved in that she was continued to have pyrexia, and her body temperature had risen to 39.2oC. Given this, she was referred to the clinic of the authors for further assessments. She had a computed tomography (CT) scan of the thorax, which demonstrated bilateral multi-focal ground-glass opacities that were associated with consolidation, which was suggestive of viral pneumonia as a differential diagnosis based upon the radiology imaging features of her pulmonary lesions. She had a subsequent test that demonstrated that her 2019-novel coronavirus pneumonia nuclei acid test result was positive, which established a definite diagnosis of 2019-novel coronavirus pneumonia. Her 2019-novel coronavirus pneumonia was resolved under her treatment. An et al. [13] concluded that computed tomography (CT) scan of thorax does offer fast and convenient evaluation of patients who are suspected of having 2019-novel coronavirus pneumonia. Some of the lessons learned from this case report include the following:
Zhang et al. [14] reported a 64-year-old man who had presented with a recurrent fever after he had caught a cold for 6 days. He stated that he had felt better undertaking anti-febrile agents. One day preceding his visit to the hospital, he developed fever again as well as dizziness, headache, aching of his four limbs, but no cough, shivering, tightness of chest, chest pain, nausea, and vomiting, et cetera. About travel history, he stated that he had traveled from Wuhan to Kunming. He did not have any significant past medical accounts, and he had never had hepatitis, tuberculosis, typhoid before as well as he had not been in contact with poultry or mosquito bites. He was admitted to the hospital of the authors on the 21st of January 2020, and he still had fever following his admission, with his highest temperature recorded as 39.2oC. He had a real-time RT-PCR test, which revealed positive results for the 2019 novel coronavirus (2019-nCoV). The undertaking of microbiology tests excluded the possibility of the man having combined infection with other pathogens, and the results were normal. He had a CT scan of thorax, which demonstrated features that simulated the CT scan of thorax features that had been previously described by Huang et al., [15] and also by Pan et al. [16] (see figure for the CT thorax of the patient). The CT scan of the thorax showed multiple patchy ground-glass opacities (GGOs in both lungs and the majority of the opacities were in sub-pleural areas. Follow-up CT scans of the thorax demonstrated that within 3 days, nodular GGOs were also revealed together with sub-pleural patchy GGOs. Multiple patchy ground-glass opacities (GGOs) were seen in bilateral lung, mostly in subpleural areas. They progressed within 3 days, and nodular GGOs were also seen together with subpleural patchy GGOs. Zhang et al. [14] emphasized that knowledge of the computed tomography (CT) scan features of COVID-19 pneumonia could be helpful about the early diagnosis and treatment of patients as well as in the control of the spread of the infection which in this case would involve isolation of the patient. Zhang et al. [14] made the ensuing conclusions:
Lessons learned from this case report include the following:
It is well known that generally, all hospital establishments within the developed countries have facilities for the undertaking of computed tomography (CT) scans of the thorax as well as magnetic resonance imaging (MRI) scans of the thorax and therefore ground glass opacities would be picked up quickly within the hospital establishments. It is also well known that within many hospitals in the developing countries where COVID-19 pneumonia cases are also being reported, CT scan and MRI scan facilities are usually not available and in the few hospitals where CT scan and MRI scan facilities are available, quite often the CT scan machines, and the MRI scanners tend to break down often. The repair work, as well as the normal return to function of the scanners, tend to be delayed, and only chest x-rays tend to be most commonly available for the assessment of respiratory tract symptoms initially. It is also known that chest x-rays generally are not capable of detecting small ground-glass opacities which does mean that if a patient has COVID-19 pneumonia and presents to the hospital, there would tend not to be facilities for CT scan or MRI scan which would expect that early detection of ground-glass opacity in such hospitals would be impossible. Hence, CT scan and MRI scan cannot be used as a radiology imaging means of detecting possible pulmonary lesions that could represent COVID-19 pneumonia and for this reason, clinicians need to be advised that if patients present with non-specific symptoms, they should have a high index of suspicion for COVID-19 pneumonia in the absence of any significant chest x-ray findings and they should quickly undertake COVID-19 tests for all their patients. In such scenarios, even if the result of the first test is negative, the patients should be initially treated but isolated, and a repeat COVID-19 test should be subsequently undertaken to confirm or negate the diagnosis of COVID-19. Considering the usefulness of CT scans in the early detection of ground-glass opacities, some of which could be related to COVID-19 and some of the ground-glasses could subsequently enlarge, it would be argued that during this COVID-19 pandemic, Governments in developing countries should find a way of getting more CT scans for hospitals that do not have CT scans as well as communities that do not have CT scans should make efforts to undertake self-help money-raising efforts to obtain sufficient money to acquire CT scans for the benefit of their health as well as extra money for the maintenance of the CT scans as a collaborative effort to support the efforts of their Governments and district councils.
A: Chest CT on admission shows multiple ground-glass opacities in bilateral lungs, mainly in the subpleural areas. B: CT image of 3 days later shows a marked progression of multiple ground-glass opacities in subpleural areas. C, D: High-resolution CT images at the same period of A and B, respectively. They show nodular ground-glass opacities in the subpleural areas in the upper lobe of the left lung, and they significantly progressed within 3 days. Reproduced from: [14] Zhang X, Song W, Liu X, Lyu L. CT image of novel coronavirus pneumonia: a case report. Jpn J Radiol. 2020 Mar 18: 1-2. DOI: 10.1007/s11604-020-00945-1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7088615/ under copyright © Japan Radiological Society 2020 This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgment of the source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.
Huang et al. [15] reported a 36-year-old man who had manifested with a 2-days history of fever, sore throat, as well as fatigue 5 days pursuant to his visiting Wuhan, in China. His temperature upon his admission was 37.8 degrees centigrade (100.04oF). The examination of his respiratory system was normal, with normal sounds upon consultation. The results of his laboratory blood tests were normal in that his white blood cell count was 4.6 x 109/L, which was normal, and his differential blood count revealed 53.1% neutrophils. His blood procalcitonin level was within a normal range. He had a computed tomography (CT) scan of thorax, which revealed multiple peripheral ground-glass opacities within both of his lungs, as well as the CT scan, demonstrated more involvement of his left upper lobe as well as the lingular segment (see figures 2 a to c). During his admission, he had a real-time fluorescence polymerase chain reaction (RT-PCR) assay of his sputum, and the result was negative for the 2019 novel coronavirus (2019-nCoV) nuclei acid. He had a repeat computed tomography (CT) scan of thorax 3 days following his admission, which demonstrated the transformation of ground-glass opacities to more consolidation (see figures 2d to 2f). He also had a repeat RT-PCR 2019-nCoV nucleic acid assay, and the result at that time was negative. Six days pursuant to his admission, he had a third RT-PCR 2019-nCoV nucleic acid assay, and the result was finally shown to be positive. Huang et al. [15] emphasized that when the specimen tests bring out negative results, the possibility of a false-negative result should be taken into consideration concerning the recent exposures of the patient as well as the presence of clinical signs and symptoms that are consistent with 2019-nCoV infection, [17] [18] [19] in addition to the history of recent exposure which did indicate that 2019-nCoV infection was the likely diagnosis.
Images in a 36-year-old man with a 2-day history of fever, sore throat, and fatigue 5 days after visiting Wuhan, China, and a negative sputum real-time fluorescence polymerase chain reaction assay for the 2019 novel coronavirus. (a, b) Chest CT scans obtained at presentation show ground-glass opacities (red box) in the right upper lobe, and the lingular segment and the left lower lobe (b). (c) Volume rendering of a chest CT scan obtained at admission. (d, e) CT scanned obtained 3 days after admission show progression of ground-glass opacities to an atoll sign in the right upper lobe (red boxes in d) and left lower lobe consolidation (red boxes in e). (f) Volume rendering of the chest CT scan obtained 3 days after admission shows the new areas of consolidation. They are reproduced from [15] Huang P, Liu T, Huang L, Liu H, Lei M, Xu W, Hu X, Chen J, Liu B. Use of Chest CT in Combination with Negative RT-PCR Assay for the 2019 Novel Coronavirus but High Clinical Suspicion. Radiology. 2020;295(1):22-23. doi:10.1148/radiol.2020200330 https://pubmed.ncbi.nlm.nih.gov/32049600/ under Copyright 2020 by the Radiological Society of North America, Inc.
This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses in any form or by any means with acknowledgment of the original source. These permissions are granted for the duration of the COVID-19 pandemic or until permits are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections.
Images in a 36-year-old man with a 2-day history of fever, sore throat, and fatigue 5 days after visiting Wuhan, China, and a negative sputum real-time fluorescence polymerase chain reaction assay for the 2019 novel coronavirus. (a, b) Chest CT scans obtained at presentation show ground-glass opacities (red box) in the right upper lobe, and the lingular segment and the left lower lobe (b). (c) Volume rendering of a chest CT scan obtained at admission. (d, e) CT scanned obtained 3 days after admission show progression of ground-glass opacities to an atoll sign in the right upper lobe (red boxes in d) and left lower lobe consolidation (red boxes in e). (f) Volume rendering of the chest CT scan obtained 3 days after admission shows the new areas of consolidation. They are reproduced from [15] Huang P, Liu T, Huang L, Liu H, Lei M, Xu W, Hu X, Chen J, Liu B. Use of Chest CT in Combination with Negative RT-PCR Assay for the 2019 Novel Coronavirus but High Clinical Suspicion. Radiology. 2020;295(1):22-23. doi:10.1148/radiol.2020200330 https://pubmed.ncbi.nlm.nih.gov/32049600/ under Copyright 2020 by the Radiological Society of North America, Inc.
This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses in any form or by any means with acknowledgment of the original source. These permissions are granted for the duration of the COVID-19 pandemic or until permits are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections.
Images in a 36-year-old man with a 2-day history of fever, sore throat, and fatigue 5 days after visiting Wuhan, China, and a negative sputum real-time fluorescence polymerase chain reaction assay for the 2019 novel coronavirus. (a, b) Chest CT scans obtained at presentation show ground-glass opacities (red box) in the right upper lobe, and the lingular segment and the left lower lobe (b). (c) Volume rendering of a chest CT scan obtained at admission. (d, e) CT scanned obtained 3 days after admission show progression of ground-glass opacities to an atoll sign in the right upper lobe (red boxes in d) and left lower lobe consolidation (red boxes in e). (f) Volume rendering of the chest CT scan obtained 3 days after admission shows the new areas of consolidation. They are reproduced from [15] Huang P, Liu T, Huang L, Liu H, Lei M, Xu W, Hu X, Chen J, Liu B. Use of Chest CT in Combination with Negative RT-PCR Assay for the 2019 Novel Coronavirus but High Clinical Suspicion. Radiology. 2020;295(1):22-23. doi:10.1148/radiol.2020200330 https://pubmed.ncbi.nlm.nih.gov/32049600/ under Copyright 2020 by the Radiological Society of North America, Inc.
This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses in any form or by any means with acknowledgment of the original source. These permissions are granted for the duration of the COVID-19 pandemic or until permits are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections.
Images in a 36-year-old man with a 2-day history of fever, sore throat, and fatigue 5 days after visiting Wuhan, China, and a negative sputum real-time fluorescence polymerase chain reaction assay for the 2019 novel coronavirus. (a, b) Chest CT scans obtained at presentation show ground-glass opacities (red box) in the right upper lobe, and the lingular segment and the left lower lobe (b). (c) Volume rendering of a chest CT scan obtained at admission. (d, e) CT scanned obtained 3 days after admission show progression of ground-glass opacities to an atoll sign in the right upper lobe (red boxes in d) and left lower lobe consolidation (red boxes in e). (f) Volume rendering of the chest CT scan obtained 3 days after admission shows the new areas of consolidation. They are reproduced from [15] Huang P, Liu T, Huang L, Liu H, Lei M, Xu W, Hu X, Chen J, Liu B. Use of Chest CT in Combination with Negative RT-PCR Assay for the 2019 Novel Coronavirus but High Clinical Suspicion. Radiology. 2020;295(1):22-23. doi:10.1148/radiol.2020200330 https://pubmed.ncbi.nlm.nih.gov/32049600/ under Copyright 2020 by the Radiological Society of North America, Inc.
This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses in any form or by any means with acknowledgment of the original source. These permissions are granted for the duration of the COVID-19 pandemic or until permits are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections.
Pan et al. [16] undertook a study to observe the radiology imaging features of the novel coronavirus pneumonia. Pan et al. [16] enrolled sixty-three confirmed patients who had CVID-19 pneumonia from 30th December 2019 to 31st January 2020. The patients did undergo High-resolution CT (HRCT) of the thorax. Pan et al. [16] recorded the number of affected lobes of the lung, ground-glass nodules (GGO), patchy/punctate ground-glass opacities, patchy consolidation, fibrous stripes as well as irregular solid nodules in each patient’s computed tomography (CT) scan of the thorax image. Furthermore, pan et al. [16] performed a radiology imaging follow-up of the patients above. About the results, pan et al. [16] emphasized that they had collected the CT scan images of the 63 patients who were confirmed to have coronavirus pneumonia (Examples of some of the CT scan images have been illustrated in figure 4 and figure 5). Pan et al. [16] summated their findings as follows:
Pan et al. [16] made the ensuing conclusions:
Considering that only 63 patients were enrolled in the study of Pan et al. [16], it would be argued that perhaps there are other radiology imaging features that some cases of COVID-Pneumonia would demonstrate. For this reason, clinicians should be encouraged to report instances of COVID-19 pneumonia they have managed as well as lessons learned from the management of COVID-19. The radiology imaging features that had been found by Pan et al. [16] are non-specific radiology image findings. Given this, we have considered various types of radiology image features that would tend to simulate some of the non-specific image features of COVID-19 pneumonia. Unfortunately, the radiology images related to the article of Pan et al. [16] are not easily available to be reproduced in a new article even though there is a clearance center with guidelines for obtaining permission to re-use images in the report. Instead, we have included images from the archives of one of the authors to illustrate possible radiology images that should alert clinicians to the possibility of COVID-19 pneumonia. In the latter part of the article, we have discussed various other radiology images that could simulate COVID-19 infection and for which necessary tests would need to be undertaken to confirm or negate COVID-19 pneumonia.
Dai et al. [20] stated that since the beginning of 2020, coronavirus disease 2019 (COVID-19) has spread throughout China. This study has explained the findings from lung computed tomography images of some patients with COVID-19. They were treated in a medical institution and has discussed the difference between COVID-19 and other lung diseases. Dai et al. [20] reported some cases of COVID19 as follows:
A 52-year-old man who had been working in Wuhan, in China, had arrived in Shenzhen in China, on the 22nd of January 2020. He requested treatment because he had a half a day symptom of fever that was associated with nasal congestion, as well as a headache. Still, he did not have any rhinorrhoea, pharyngula, cough, expectoration, or diarrhea. The results of his laboratory blood tests demonstrated a low lymphocyte count of 0.58 x 109/l, a high neutrophil percentage of 81.3%, a high procalcitonin concentration of 0.130 ng/mL, a high-sensitivity C-reactive protein (hs-CRP) concentration of 7.80 mg/l, a normal white blood cell (WBC) count of 6.62 x 109/L, as well as normal concentrations of creatinine kinase-myocardial band, cardiac troponin 1, as well as myoglobin. He had an unenhanced CT scan of the thorax, which demonstrated patchy pure ground-glass opacities (GGOs) within the lateral basal segment of his right lower lobe lung as well as vascular dilatation inside the lesion (see figure 3). He was suspected of having early staged COVID 19 pneumonia. The NAAT result that was obtained by utilization of RT-PCR identification of SARS-CoV-2 from his respiratory tract specimens was reported to be positive, and hence he was diagnosed as having COVID-19.
Figure 3. A 52-year old male: Computed tomography scan revealed patchy pure ground-glass opacities (red arrow) at the lateral basal segment of the right lower lobe and vascular dilation inside the lesion. Reproduced from: [20] Dai W C, Zhang H W, Yu J, Xu H J, Chen H, Luo SP, Zhang H, Liang L H, Wu X L, Lei Y, Lin F. CT Imaging and Differential Diagnosis of COVID-19. Can Assoc Radiol 2020 May; 71(2): 195 – 200 DOI: 10.1177/0846537120913033. https://pubmed.ncbi.nlm.nih.gov/32129670/
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A 63-years-old man who had taken a high-speed train from Wuhan to Beijing on the 10th of January 2020 did arrive in Shenzhen by plane from Beijing on the 26th of January 2020. He was admitted to hospital, given him having a fever over the preceding 5 days pursuant to catching a cold, and his highest body temperature was 37.7oC. He also had an occasional cough as well as myalgia, but this was not associated with expectoration or dyspnoea. The results of his laboratory tests revealed elevated hs-CRP of 33.57 mg / L, normal procalcitonin level of 0.072 ng / mL, a normal neutrophil count of 2.50 x 109/L, a normal lymphocyte count of the level of 1.11 x 109/L, a normal white blood cell (WBC) count of 3.99 x 109/L, as well as a normal lymphocyte percentage of 27.8%. He had an unenhanced computed tomography (CT) scan of the thorax which revealed multiple pure ground-glass opacities (GGOs) within the right upper lobe of his lung, distribution of lesions within the sub-pleural area and the periphery of the lung, a ”crazy-paving” pattern, as well as interlobular septal thickening (see figure 4). Based upon the computed tomography (CT) scan of thorax features, the patient was provisionally suspected to be affected by advanced-staged COVID19. The result of his NAAT test that was obtained by means of the undertaking of RT-PCR detection of SARs-2 from the patient’s blood specimens was positive, which confirmed the diagnosis of COVID-19.
A 63-year-old male: High-resolution computed tomography scan showed multiple pure ground-glass opacities in the right lobe, distribution of lesions in the subpleural area, and lung periphery, a “crazy-paving” pattern, and interlobular septal thickening (red arrow). Reproduced from: [20] Dai W C, Zhang H W, Yu J, Xu H J, Chen H, Luo SP, Zhang H, Liang L H, Wu X L, Lei Y, Lin F. CT Imaging and Differential Diagnosis of COVID-19. Can Assoc Radiol 2020 May; 71(2): 195 – 200 DOI: 10.1177/0846537120913033. https://pubmed.ncbi.nlm.nih.gov/32129670/
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Case 3 involved a 48-years-old man who had been quarantined at home after he had driven himself from Wuhan to Shenzhen on the 24th of January 2020. He was admitted to hospital because of having pharyngula over the preceding 4 days as well as a fever that had lasted over the previous 1 day. His temperature upon his admission was 38.5oC. He did not have any evidence or history of cough, expectoration, headaches, myalgia, nasal congestion, rhinorrhea, or dyspnoea. The results of his laboratory blood test, demonstrated elevated serum hs-CRP level of 73.99 mg/mL, increased procalcitonin concentration level of o.100 ng / mL, a decreased lymphocyte count level of 0.92 x 109/L, and a normal white blood cell (WBC) count of 5.54 x 109/L. He had unenhanced computed tomography (CT) scan of the thorax that demonstrated multiple ground-glass opacities (GGOs) within both of his lungs, inter-septal thickening, as well as a “crazy-paving pattern” (see figure 5). Based upon the computed tomography (CT) scan of the thorax features of the patient, he was provisionally diagnosed as having advanced-stage COVID-19. The result of his NAAT, which was obtained by the undertaking of RT-PCR detection test for SARS-CoV-2 from his pharyngeal swabs, was positive for COVID-19, and he was diagnosed as having COVID-19.
A 48-year-old male: High-resolution computed tomography scan showed multiple ground-glass opacities in numerous lobes of both lungs, interlobular septal thickening, and a crazy-paving pattern (red arrow). Reproduced from: [20] Dai W C, Zhang H W, Yu J, Xu H J, Chen H, Luo SP, Zhang H, Liang L H, Wu X L, Lei Y, Lin F. CT Imaging and Differential Diagnosis of COVID-19. Can Assoc Radiol 2020 May; 71(2): 195 – 200 DOI: 10.1177/0846537120913033. https://pubmed.ncbi.nlm.nih.gov/32129670/
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This case involved a 47-year-old male who was a resident of Shenzhen and who had been within close contact of less than 2 meters recently with a driver from Wuhan. He had had a fever for the preceding 4 days even though he had used non-prescription medications, because of the sought treatment within the hospital His body temperature was 40oC as well as he had diarrhea twice per day. Still, he did not have any cough, expectoration, myalgia, dysuria, or dyspnea. The results of his laboratory blood tests revealed a low percentage of lymphocytes of 14.4%, a low lymphocyte count of 0.90 x 109/L, a high hs-CRP concentration of 136.51 mg/L, a high procalcitonin concentration of 0.180 ng / mL, a normal neutrophil percentage of72.2% and a normal white blood cell (WBC) count of 6.27 x 109/L. He had un-enhanced computed tomography (CT) scan of the thorax that demonstrated patchy consolidations upon his left upper lobe lung and partially consolidated lung tissue, ground-glass opacities (GGOs) on edge, and air bronchograms within the lesion (see figure 6). The result of his NAAT that was based upon RT-PCR detection of SARS-CoV-2 from a specimen of his blood was positive for COVID-19, and therefore a final diagnosis of COVID19 was made.
A lesson that has been learned from those above 4 reported cases is the fact that instances of advanced-stage or well-established cases of COVID would tend to demonstrate upon radiology imaging of CT scan of thorax evidence of various opacities within the lung including ground-glass opacities pari passu positive COVID-19 test results and given this within the era of COVID19 pandemic any individual who has respiratory tract symptoms which are shown upon radiology imaging to have pulmonary metastasis should be made to undergo COVID-19 to clarify the situation.
A 47-year-old male: High-resolution computed tomography scan showed patchy consolidations on the left upper lobe, partially consolidated lung tissue, ground-glass opacities on edge, and air bronchograms in the lesion (red arrow). Reproduced from: [20] Dai W C, Zhang H W, Yu J, Xu H J, Chen H, Luo SP, Zhang H, Liang L H, Wu X L, Lei Y, Lin F. CT Imaging and Differential Diagnosis of COVID-19. Can Assoc Radiol 2020 May; 71(2): 195 – 200 DOI: 10.1177/0846537120913033. https://pubmed.ncbi.nlm.nih.gov/32129670/
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Dai et al. [20] made the ensuing iterations:
Case 5 (Case 1 in Dai et al. [20])
A 60-year-old woman who did not have any recent history of exposure to the COVID-19 pandemic area was admitted to hospital because she had been coughing for 10 days. She also had chest pain and had been wheezing over the preceding 3 days, as well as she had been producing yellow sputum. She had been taking cephalosporin antibiotics by herself before seeking treatment within the hospital, but her symptoms had not improved. She did not have any fever, headache, rhinorrhea, nausea, or vomiting. She did have a medical history of rheumatoid arthritis for more than 10 years. The results of her laboratory blood test, demonstrated a normal white blood cell (WBC) count of 4.96 x 109/l, a normal neutrophil percentage of 48.6%, a normal procalcitonin level, as well as a normal lymphocyte count status. He had a plain chest x-ray, which demonstrated extensive patchy exudates as well as consolidation upon both of his lungs, faint ground-glass opacity (GGOs) upon the edge, as well as interlobular septal thickening (see figure 7). The result of her NAAT that was obtained using the RT-PCR detection test for SARS-CoV-2 from her respiratory tract specimens was negative for COVID-19. The results of her additional laboratory blood tests revealed high hs-CRP of 40.20 mg / L, high D-dimer of 2.22 mg / L, high immunoglobulin G level of 19.3 g/L, as well as positive rheumatoid factor. Her final diagnosis was rheumatoid pneumonia. The lesson learned from this case report is that not all cases that are provisionally diagnosed as possible COVID19 are COVID19.
A 60-year-old female: High-resolution chest computed tomography scan revealed extensive patchy exudates and consolidation of both lungs, faint ground-glass opacities on edge, and the interlobular septal thickening (red arrow). Reproduced from: [20] Dai W C, Zhang H W, Yu J, Xu H J, Chen H, Luo SP, Zhang H, Liang L H, Wu X L, Lei Y, Lin F. CT Imaging and Differential Diagnosis of COVID-19. Can Assoc Radiol 2020 May; 71(2): 195 – 200 DOI: 10.1177/0846537120913033.https://pubmed.ncbi.nlm.nih.gov/32129670/
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Case 6 (Case 2 in Dai et al. [20]).
A 58-year-old woman from Henan and who had recently passed through Wuhan had manifested with recurrent chest pain for 1 month. She was admitted to hospital 2 hours under aggravation of her chest pain. She did not have any fever, cough, dizziness, or headache, but she did have a history of hypertension for longer than 10 years. She had a computed tomography (CT) scan of thorax, which demonstrated extensive ground-glass opacities (GGOs) within both of her lungs, which was mainly distributed along her hila, interlobular septal thickening, as well as inter-lobar pleural thickening (see figure 8). She had a computed tomography (CT) scan of the thorax, and based upon the features that were demonstrated by the CT scan of thorax, the possibility of COVID19 could not be excluded. The result of her NAAT test that was obtained using RT-PCR detection of SARS-CoV-2 from specimens of her tract was noted to be negative. The results of her laboratory blood test did not reveal any abnormality in her D-dimer concentration, white blood cell count (WBC), or hs-CRP concentration. She had echocardiography, which demonstrated low-amplitude left ventricular wall motion as well as low diastolic function. She had electrocardiography, which showed ST elevation in lead aVR of 0.05 mV as well as multi-lead ST depression of 0.1 to 0.2 mV. She had digital subtraction angiography, which did suggest occlusion of her left anterior descending coronary artery. A final diagnosis of heart failure and pulmonary edema that had been caused by coronary heart disease and acute myocardial infarction was made. The lesson learned from this case report is that cardiopulmonary conditions, including heart failure related to coronary artery disease, myocardial infarction, and pulmonary edema, can mimic COVID19 pneumonia.
A 58-year-old female: High-resolution chest CT showed extensive GGOs in both lungs, which were mainly distributed along the hila, interlobular septal thickening, and interlobar pleural thickening (red arrow). Reproduced from: [20] Dai W C, Zhang H W, Yu J, Xu H J, Chen H, Luo SP, Zhang H, Liang L H, Wu X L, Lei Y, Lin F. CT Imaging and Differential Diagnosis of COVID-19. Can Assoc Radiol 2020 May; 71(2): 195 – 200 DOI: 10.1177/0846537120913033. https://pubmed.ncbi.nlm.nih.gov/32129670/
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Xu et al. [21] reviewed data related to all patients who had a laboratory test identified cases of SARS-CoV-2 infection that were confirmed based upon real-time polymerase chain reaction (PCR) between 23rd January and 4th February 2020 within a designated hospital called Guangzhou Eighth People’s hospital. Ninety (90) patients, which included 39 males and 51 females whose ages had ranged between 18 years and 86 years and whose median age was 50 years, were included in the review study. Xu et al. [21] emphasized that all of the patients who had SARS-CoV-2 infections had undergone non-contrast-enhanced computed tomography (CT) scan. Xu et al. [21] did analyze the clinical features of the patients, and they also analyzed the distribution characteristics, the pattern of the disease, the morphology of the disease, as well as the accompanying presentations of the lung lesions. They evaluated after 1 day to 6 days with a mean time of after 3.5 days; they assessed the follow-up computed tomography (CT) scan of thorax images of the patients to ascertain the radiological evolution of the disease. Xu et al. [21] summated their findings as follows:
Xu et al. [21] made the ensuing concluding stipulations:
Zhou et al. [22] undertook a retrospective observational study that was based upon data that had been collected between 19th January 2020 and 15th February 2020 on patients who had been diagnosed as having COVID-19 for which they had been treated. They reviewed the clinic workflow with the utilization of computed tomography (CT) scan of the thorax and RT-PCR assay to screen patients who are suspected of having COVID-19 pneumonia. The clinical data of the patients were evaluated, and the patients had been classified into (a) mild group, (b) common group, (c) severe group, and (d) critical group. They evaluated the computed tomography (CT) scan of the thorax features of each patient, and they did apply a CT scan scoring system to grade the involvement of the lung by the COVID-19. Zhou et al. [22] summarized the results as follows:
Zhou et al. [22] made the ensuing conclusions:
De Farias et al. [23] summarized the role of chest x-ray in COVID-19 infection as follows:
De Farias et al. [23] also made summations related to the undertaking of computed tomography scan of the thorax in cases of COVID-19 as follows:
De Farias et al. [23] also said the ensuing:
De Farias et al. [23] made the ensuing conclusions:
Zheng et al. [42] made the ensuing summations related to COVID-19 infection:
Recommendations for categorizing computed tomography findings of COVID-19 pneumonia. Adapted from Simpson et al. [8] [new 30]. Simpson S, Kay FU, Abbara S, Bhalla S, Chung JH, Chung M, et al. Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA. J Thorac Imaging. 2020. https://doi.org/10.1097/RTI.0000000000000524] and from Da Farias et al. [23]
A Pulse Oximeter can show lung hypoxia in Covid19 Pneumonia, which appears to be a game-changer in distinguishing it from other causes of Pneumonia and infections.
The following images are a random selection of a series of Chest Radiographs, and computed tomography (CT) scans that show consolidations, lung volume loss, air-bronchograms, Ground-Glass opacification, pleural effusions & nonspecific linear shadowing. The abnormalities that have been demonstrated below are indistinguishable from COVID 19 Pneumonia on imaging alone. The images are randomly chosen from the author's archives of several hundred x-ray films and computed tomography (CT) scans. A Pulse Oximeter reading for hypoxemia is crucial. The images that have been illustrated below should alert clinicians to the possibility of a diagnosis of COVID19 which they should exclude by undertaking the COVID19 test
Figure 10. Case 1 of our series
Figure 10 does illustrate a chest x-ray of an individual that had demonstrated collapse/consolidation of the right upper lobe of the lung. This appearance is non-specific, but it tends to be associated with a wide number of differential diagnoses, but COVID19 pneumonia should be the minds of clinicians when they see radiology images as illustrated below (see figure 10). In this particular case,a series of chest x-rays (CXRs) and High-resolution computed tomography scans (HRCTs) showed calcified pleural plaque, and lung parenchymal shadowing in a patient with a history of asbestos exposure, basal linear shadowing, and pericardial effusion (not shown). Nevertheless, it does represent one radiology image feature that should alert clinicians to exclude COVID19 pneumonia. Radiograph reproduced from our archives of Klaus.
Figure 15: Case 2 shows a chest x-ray of a patient who had presented with cough, fever, and shortness of breath. The chest Radiograph shows nonspecific bi-basal shadowing, and during the COVID19 pandemic, the finding of non-specific finding as illustrated in figure 15 should alert the clinician to undertake tests to exclude COVI19 pneumonia even though case 2 was not a case of COVID19 but does mimic non-specific feature that may be seen in COVID19 pneumonia. The image was reproduced from the archives of Klaus, a co-author of this article.
Figure16 represents axial CT scans on the same patient (case 2) whose chest x-ray (CXR) was illustrated in Figure 15 show extensive calcified pleural plaques (white arrow) but no other lung parenchymal abnormality. The patient's symptoms were un-explained, which settled without intervention. The case was not that of COVID19 but the chest x-ray features are non-specific which could also be seen in some cases of COVID 19 pneumonia and the finding of chest x-ray features as illustrated in figure 15 should alert the clinician to have a high index of suspicion to exclude COVID19 pneumonia by undertaking COVI19 tests. The images have been reproduced from the archives of Klaus, a co-author of this article.
Figure 17 represents a chest x-ray of another patient (case 3) who presented with exertional dyspnea, and the chest x-ray shows ground-glass opacification at the lung bases that had been illustrated by a star. The chest x-ray finding, in this case, is non-specific and could be demonstrated in a number of differential diagnoses but the finding of a chest x-ray feature as illustrated in figure 17 should alert the clinician to undertake COVID19 test to confirm or negate the diagnosis of COVID19 pneumonia in the current COVID19 pandemic era.
A radiograph of a patient that presented with exertional dyspnea shows ground-glass opacification at the lung bases (star). The Radiograph was reproduced from the personal archives Klaus, a co-author of this article.
Figure 18 represents axial CT scans of the same patient (case 3) whose chest x-ray was illustrated in Figure 18, and these show subtle ground-glass appearance and sub-pleural reticular shadowing. The cause was Collagen vascular-related lung disease. The features that are demonstrated in the figure are non-specific and should alert the clinician to undertake the COVID19 test to exclude or negate the diagnosis of COVID 19 pneumonia. The figure was reproduced from the archives of Klaus, a co-author of this article.
Many causes of Pneumonia have been described. Pneumonia can occur at any age, and presentation can be non-specific. Various imaging techniques generally diagnose cases of Pneumonia. In the current climate, COVID-19 Pneumonia has taken center stage; confirmation relies upon microbiological studies such as real-time polymerase chain reaction or sequencing. These investigations are not usually available in an emergency setting. Computed Tomography (CT) can be used as an essential complement for the diagnosis of COVID-19 Pneumonia in the current epidemic context. But the later may be misleading as other cases of Pneumonia, and interstitial lung disease can easily be confused with COVID-19 Pneumonia. Also, COVID-19 Pneumonia may be missed if not considered.
Conflict of interest: - None
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